Basic Information
Provider Information | |||||||||
NPI: | 1457338584 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLEASANT CARE CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PLEASANT CARE RIVERSIDE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2258 FOOTHILL BLVD | ||||||||
Address2: | SUITE 6 | ||||||||
City: | LA CANADA | ||||||||
State: | CA | ||||||||
PostalCode: | 910111476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8182489808 | ||||||||
FaxNumber: | 8185417072 | ||||||||
Practice Location | |||||||||
Address1: | 8781 LAKEVIEW AVE | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925095969 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516851531 | ||||||||
FaxNumber: | 9516854544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PADRE | ||||||||
AuthorizedOfficialFirstName: | JOE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
AuthorizedOfficialTelephone: | 8182489808 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | ZZT05815J | 05 | CA |   | MEDICAID |